Healthcare Provider Details

I. General information

NPI: 1891873139
Provider Name (Legal Business Name): COASTAL EYE SPECIALISTS MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 09/11/2025
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 N ROSE AVE SUITE 200
OXNARD CA
93030
US

IV. Provider business mailing address

1700 N ROSE AVE SUITE 200
OXNARD CA
93030
US

V. Phone/Fax

Practice location:
  • Phone: 805-983-0700
  • Fax: 805-983-7492
Mailing address:
  • Phone: 805-983-0700
  • Fax: 805-983-7492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberLIAOOD OPT115TPA
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberG50251
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberA92760
License Number StateCA

VIII. Authorized Official

Name: W LEE WAN
Title or Position: PRESIDENT
Credential: MD
Phone: 805-983-0700